Psychological distress among people living with chronic medical illness and the general population, Northwest Ethiopia: A comparative cross-sectional study

Background Psychological distress is often linked to and negatively affects the outcomes of chronic medical conditions; however, data on psychological distress and its predictors among individuals with chronic medical illnesses are scarce in developing countries like Ethiopia. The main objective of this study was to assess the magnitude and predictors of psychological distress among people living with chronic medical illness and the general population. Methods A comparative cross-sectional study was conducted in Mecha demographic research center, Northwest Ethiopia. The participants were selected from the general population and outpatient departments. Kessler-10 (K-10) was used to assess psychological distress. Result The magnitude of psychological distress among people living with chronic medical illness and those from the general population was 62.0% and 35.1%, respectively. The odds of psychological distress in people living with chronic medical illness was three times more than the one in the general population. Divorced marital status, family history of chronic medical illness, and low social support were statistically significantly associated with psychological distress in both groups. Conclusion The magnitude of psychological distress was significantly higher among people living with chronic medical illness. Routine screening of such cases for psychological distress during their visits for their medical illness helps take appropriate therapeutic interventions.


Introduction
Mental disorders, which include psychological distress remained at the top of the global burden of disease. This has been highly worsened by the recent COVID-19 pandemic [1,2]. Psychological distress is a state of emotional suffering characterized by symptoms of depression and anxiety which often co-exist with somatic complaints. It is a highly prevalent and disabling condition affecting about 10% of the world's population once in their lifetime [3]. The 2010 Global Burden of Disease Study showed that major depression was the second leading cause of disability and a major contributor to the burden of suicide and ischemic heart disease [4,5].
Three-quarters of individuals affected by psychological distress are found in low-income countries [6]. It is considered a silent epidemic throughout Africa due to substantial financial and systemic challenges [7]. Many factors are known to be associated with mental health problems [8]. Psychological distress is influenced by demographic factors, such as age, gender, lowest socioeconomic status, poorer physical health, low educational status, homelessness, and unemployment [4,6,9].
An epidemiological study done on mental disorders in Kenya found a 10.8% prevalence rate with no gender difference. Significant risk factors were age and the presence of physical illness [10]. A community-based cross-sectional study conducted in Northeast Ethiopia showed that the prevalence of common mental disorders was 32.4%. Being female, no formal education and low level of education, having a small family size, family history of mental illness, living with chronic illness, active smoking, and experiencing one or more stressful life events were significantly associated with common mental disorders. On the other hand, a high level of emotional support reduces the likelihood of occurrence of psychological distress by half [11].
Psychological distress is often linked to and worsens the outcomes for chronic diseases such as cancer, cardiovascular diseases, diabetes, tuberculosis, and HIV/AIDS due to its effect to have unhealthy and risky behavior, non-adherence to prescribed medical regimens, and diminished immune functioning [5]. Untreated psychological distress resulted in poor control of sugar level in diabetes mellitus; worse treatment outcomes, poorer quality of life and greater disability in tuberculosis; uncontrolled seizure in epilepsy; and high blood pressure in hypertension [12][13][14][15]. However, the magnitude and predictors of psychological distress among people living with chronic medical illness in low-income countries like Ethiopia remain underresearched. Hence, this study aimed at determining the magnitude and identifying predictors of psychological distress among people living with chronic medical illness in comparison with the general population in Northwest Ethiopia. The research hypothesis was that psychological distress was more prevalent among people living with chronic medical illness than in the general population. The findings of the study help increase the health care providers' awareness of the magnitude of psychological distress and its predictors among both groups of the population. This, in turn, leads to early diagnosis and treatment of mental distress and improves treatment outcomes and quality of life.
April 2018. A facility-based sample of individuals who were diagnosed with chronic medical diseases (hypertension, tuberculosis, diabetes mellitus, HIV/AIDS, epilepsy, and asthma) was compared to a community-based representative sample of healthy individuals.

Target population
The target population included all individuals living in the Mecha district for at least six months, the minimum time duration one needs to qualify to be a resident in the district under local regulations.

Inclusion and exclusion criteria
People living with chronic medical illness. All adults aged 18 years and above who have treatment follow-up for chronic medical illnesses at health facilities in the study district for at least 6 months were included in the interview.
Participants from the general population. All people aged 18 years and above who have been living in the area for at least six months were invited for the interview. Those who reported known chronic medical illnesses were excluded to control a potential confounding effect.

Sample size and sampling procedures
The sample size was calculated using Epi info StatCalc for a comparative cross-sectional study with a confidence interval of 95%, statistical power of 80%, level of significance of 5%, psychological distress among people attending outpatient departments for chronic diseases, and among community dwellers of 42.4% [13] and 32.4% [11], respectively with equal ratio. The sample size calculated was 387 for each of the two groups. A design effect of two was used to calculate the actual final sample size. A total of 1548 respondents were recruited for both groups.
The government health facilities in the study area were selected with a lottery method. The list of all catchment kebeles (districts) for the selected health facilities were obtained. The multistage sampling went on by taking a sample of Kebeles, villages, and then households using a lottery method. Proportional allocation of the calculated sample size to the selected villages and health facilities was done based on the proportion of people living with chronic medical illness in the health facilities. Finally, participants from the selected households and health facilities were recruited by a systematic random sampling.

Data collection tools, procedures, and measurements
Six data collectors and two supervisors were selected and given a two-day training. With daily supervision, the data was collected via face-to-face interview using a pre-tested structured questionnaire consisting of socio-demographic and psychosocial variables.
Socio-demographic variables included sex, age (in years), marital status, educational status, occupation, and monthly income (in Ethiopian birr, quartiles).
The psycho-social variables were family history of medical illness (yes, no) and mental illness (yes, no), family size, living condition (lives with family, relatives, alone, homeless), types of drugs (one, two, or more), duration of medication (0-5 years, > 5 years), stressful life events, and social support.
Psychological distress was assessed using K-10, a 10-item scale validated in Ethiopia and found in the Amharic version. It has a 5-point Likert scale from zero to four: 0 (none of the time), 1 (a little of the time), 2 (some of the time), 3 (most of the time), and 4 (all of the time).
The total score for an individual ranges from zero to forty [16]. It measures the psychological distress experienced by people in the last 30 days before the study [17]. It has very good psychometric properties, 84.2% sensitivity and 77.8% specificity at a cut-off threshold of a minimum of 7 out of 40 [16,18]. This cut-off point was used in this study to dichotomize psychological distress. A Cronbach's alpha (0.94) demonstrated a high level of internal consistency for the K-10 items in this study.
Stressful life events were assessed using the List of Threatening Events (LTE), a 12-item self-report questionnaire. Participants indicated if these life events occurred in the six months before the data collection giving a total score of zero to twelve [19,20]. It showed a Cronbach's alpha of 0.46 in this study.
The level of social support was assessed using the Oslo Social Support Scale (OSSS-3), a selfreported 3-item measure of the number of confidants, sense of concern from people, and relationship with neighbors for practical help. The scores range from 3-14 with 3-8 (poor support), 9-11 (moderate support), and 12-14 (strong support) [21]. It showed a Cronbach's alpha of 0.53 in this study.

Data handling and analysis
The data were entered, coded, checked, and cleaned using Epi-data version 3.1 and exported to SPSS version 26 for analysis. Descriptive analysis was used to assess sociodemographic and other study variables. Factors with P-value < 0.20 on bivariable logistic analysis were entered into multivariable logistic regression. Statistical significance was determined at p-value < 0.05. The strength of association was interpreted using odds ratio and 95% confidence interval.

Ethical consideration
Ethical clearance was obtained from the Institutional Review Board (IRB) of Bahir Dar University (IRB code number: አህጤኢ ም/ቴ/ሽ/ዳ/1/799). Permission and support letters were secured from the Amhara National Regional State Health Bureau and the administration offices of the study Kebeles and Health Centers. Written informed consent was obtained from each respondent. The respondents were given the right to refuse to take part in the study as well as to withdraw at any time during the study. Refusal to participate did not result in loss of medical care provided or any other benefits. No name or identifying information was indicated on the questionnaire, and all subjects were assured of confidentiality. Study participants found to have severe psychological distress were referred to the psychiatry clinic.

Socio-demographic data of participants
Data were collected and analyzed from 707 individuals living with chronic medical illness and 776 participants from the general community giving a response rate of 95.7%. The mean age in years in chronic illness and community participants was 43.77 (±17.1) and 35.14 (±14.9), respectively. The two groups were compared for differences in their basic socio-demographic characteristics (Table 1) and psycho-social factors ( Table 2).

Psychological distress in the general population
The magnitude of psychological distress in the general population was 35
Males with chronic medical illness had psychological distress two times higher than those from the community (60.7% versus 29.5%). Besides, females in the chronic illness group had higher psychological distress than those in the community (63.1% versus 39.5%) ( Table 5).

Discussion
This study demonstrated that the burden of psychological distress was much higher among the chronic medical illness participants (62.0%, 95% CI, 58.7-65.5%) than the general population participants (35.1%, 95% CI, and 31.7-38.7%). It also indicated that this difference was statistically significant between the two groups. The odds of psychological distress among people with chronic medical illness was 3.2 times higher than the community sample. This was in line with and supported by a study that showed a three times higher risk of psychological distress among individuals with comorbid chronic medical illness than participants with no comorbid chronic medical illness [22]. The relationship between chronic disease and mental illness is generally thought to be bidirectional. People living with a serious mental illness are at higher risk of experiencing a wide range of chronic physical conditions. Conversely, people living with chronic medical conditions experience psychological distress twice the rate of the general population [23]. Among people living with chronic medical diseases, the study showed findings similar with those of other studies carried out in Ethiopia (63.3%) [24], Pakistan (60.2%, [25], Nigeria (64.4%) [26], and Delhi India (58.7%) [27]. However, the magnitude of psychological distress in this study was higher than that in studies done in Southern Ethiopia (39.2%) [28], Addis Ababa, Ethiopia (53.1%) [29], India (50.8%) [30], Kenya (42.3%) [31] and Iran (14%) [32]. These variations might possibly be a result of differences in sample size, inclusion criteria, screening instrument used to assess psychological distress, and the difference in the study population. In India, only 130 participants living with diabetes or hypertension were included in the study and they used General Health Questionnaire (GHQ 12) to assess psychological distress. The two studies from Ethiopia used Self-Reporting Questionnaires (SRQ-20).
The magnitude of psychological distress among the general population in this study was higher than in other community studies done in different parts of Ethiopia: Harari Regional State (14.9%), Addis Ababa (17.7%), Jimma Town (22.7%), and Illu Ababore Zone (27.2%) [33][34][35][36]. This might be due to the differences in screening tool (Self-Reporting Questionnaire-20), study period, and sociodemographic characteristics. For instance, the proportion of female participants was higher in this study than in the study in Harari Regional State (55.4% versus 38.1%). In that study, women had a higher magnitude of of depression and anxiety than men [37]. On the other hand, the psychological distress in the current study was lower than that in a study in Silte Zone residents of Ethiopia (39.7%) [38]. This might be due to the fact that none of the study participants in Silte Zone had strong social support. In the current study, 29.5% had strong social support. Low social support is known to be associated with the risk of developing psychological distress or worsening of an already existing mental health problem [39]. An other possible explanation for the difference is that the proportion of respondents having a family history of mental illness in the current study was lower (2.8% versus 49.8%).
From the multivariable logistic regression analysis among chronic medical illness study participants, it was found that individuals who were single or divorced, having family history of medical illness, low social support, and taking two or more types of drugs were likely to have psychological distress. The result was consistent with findings of other studies [22, 28,  40]. Marriage is the central part of all human society and its effects on mental illness are often identified as a key component [41]. Research consistently has shown that divorced/ widowed marital status was positively associated with smoking, poor quality of life, high psychological distress, anxiety, and depression [42]. Being married brings social support which is a very crucial role in an individual's life satisfaction and lack of social support can be a predictor of psychological problems relating to low self-esteem, loneliness, anxiety, and depression [43]. A systematic review and meta-analysis among people living with HIV/AIDS in Ethiopia showed a higher odds of depression among individuals with poor social support than those who had strong social support [44].
On the other hand, the study indicated that being female, divorced or widowed marital status, family history of medical illness, family history of mental illness, stressful life events, and low social support were factors significantly associated with psychological distress among community participants. This result was also consistent with findings of previous studies [35,36,38,40,45]. Disrupted marital status, low social support, having a family history of mental illness and stressful life events were strong risk factors to develop psychological distress.

Implication of the study
The study found a high magnitude of psychological distress among people with chronic medical conditions. This undiagnosed and untreated high psychological distress may lead to nonadherence to treatment and poor control of medical conditions. Studies showed that untreated psychological distress resulted in poor control of sugar level in diabetes mellitus [12]; worse treatment outcomes, poorer quality of life and greater disability in tuberculosis [13]; uncontrolled seizure in epilepsy [14]; and high blood pressure in hypertension [15]. The findings of this study increase the awareness among health care providers of the high magnitude of psychological distress among people living with chronic medical conditions so that its diagnosis and treatment may lead to improved treatment outcomes and quality of life of such cases.

Strengths and limitations of the study
To the best knowledge of the authors, this is the first study that compared psychological distress between people living with chronic medical diseases and the general population in Northwest Ethiopia. The other major strength of the study was that the outcome variable was assessed by using locally validated instrument having very good psychometric properties, Kessler-10. An important limitation of the study was that screening for chronic medical conditions like HIV, diabetes mellitus and hypertension was not done in the general community. In addition, authors want to stress that the tools used to measure stressful life events and social support have been found to have low Cronbach's alpha. This might partly be due to the fact that the tools have few items. Scales with short list of items have difficulties in achieving high Cronbach's alpha for it strongly depends on the number of items. Shorter scales may be considered reliable even when Cronbach's alpha is below 0.7 which may be as low as 0.5 for a three-item scale [52]. Generally, we recommend readers of this paper to remain cognizant of the problematic points behind the interpretation and effects of low values of Cronbach's alpha as a measure of reliability of scales.

Conclusion
Compared to the general population, people living with chronic medical illnesses had a high magnitude of psychological distress. Marital status, family history of medical illness, and low social support were statistically significant predictors of psychological distress in both comparative groups. The emotional dimension of chronic medical illnesses should always be given due consideration during the provision of medical care. Future studies should focus on the impact of diagnosis and treatment of psychological distress on the outcome and quality of life of people living with chronic medical illness.
Supporting information S1 Table. Bivariable and multivariable logistic analysis of variables associated with psychological distress among all study participants in Mecha demographic research center, Ethiopia. (DOCX)